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8 years of HAART for HIV
9%
9/101
Chronic hepatitis C without interferon therapy
52%
53/101
Diagnosis of rheumaoid arthritis (RA) at the age of 28, managed with herbal medicine
22%
22/101
Untreated syphilis
2%
2/101
Diagnosis of type 1 diabetes at the age of 16 with intermittant periods of poor control
14%
14/101
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This patient with nephrotic syndrome, low serum C3 levels, and "tram-tracking" on kidney biopsy has type I membranoproliferative glomerulonephritis (MPGN). Chronic hepatitis C can result in type I MPGN. MPGN is a nephrotic syndrome with two distinct forms. Type I is generally a slower disease secondary to systemic lupus erythematosus (SLE), chronic hepatitis C, or hepatitis B. Type II is a more aggressive disease caused by autoimmune activation of complement by nephritic factor, an autoantibody against C3. Both type I MPGN and type II MPGN share the laboratory findings of low serum C3; however only type II is associated with C3 nephritic factor. These two forms of MPGN can also be distinguished on biopsy. Type I shown "tram-tracking" (Figure 1), and type II shows intramembranous dense deposits. Treatment for MPGN is prednisone with or without plasmapheresis or interferion-alpha, and prognosis is poor. In a review of management for chronic hepatitis C, Moyer et al. list type II cryoglobulinemia, MPGN, and porphryria cutanea tarda as the most common extra-hepatic ramifications of the disease. Curently, about 1.8% of the American population has been infected with hepatitis C. In a 2013 review article regarding glomerulonephritis secondary to hepatitis C, Tang et al. remind readers that patients with hepatitis C-associated gromerulonephritis should be treated with pegylated interferon-alpha and ribavirin to address the underlying cause. Figure A shows a a silver stained kidney biopsy from a patient with MPGN. Note the "tram-traking" (two separate layers of the basement membrane). Illustration A shows a silver stained kidney biopsy of a patient with focal segmental glomerular sclerosis (FSGS). Note the focuses of sclerosis and hyalinosis. Illustration B depicts a kidney biopsy from a patient with renal amyloidosis. Left: light microscopy showns congo red staining of amyloid. Right: polarized light causes amyloid to appear green ("apple green birefringence.") Illustration C shows an electron microscopy (EM) view of a kidney biospy from a patient with membranous nephropathy. Note the "spike and dome" appearance caused by the formation of IgG and C3 sub-epithelial deposits. Illustration D shows an H&E stained kidney biopsy is from a patient with diabetic nephropathy. Note the Kimmelstiel-Wilson lesions and glomerular sclerosis. Incorrect answers: Answer 1: HIV is associated with focal segmental glomeruloscerolsis (FSGS). Pathology of FSGS is notable for discrete focuses of sclerosis and hyalinosis (Illustration A). Answer 3: Chronic inflammatory disease such as RA are associated with renal amyloidosis. Biopsy is notable for positive staining with congo red and apple-green birefringence (Illustration B). Answer 4: Syphilis is associated with membranous nephropathy. Biopsy would show "spike and dome" appearance on EM (Illustration C). Answer 5: Uncontrolled diabetes is associated with diabetic nephropathy. Biopsy is notable for sclerosis and Kimmelstiel-Wilson lesions (Illustration D).
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